4.1 Cost of Services

4.1.1 Costs WorkSafe pays | 4.1.2 Reasonable costs | 4.1.3 Exceptional circumstances - above rates | 4.1.4 THP reports

Workers are entitled to be compensated for reasonable costs of medical and like services incurred as a result of a work-related An injury/disease is work related if it arose out of or in the course of employment and the scope of employment. injury or illness.

Workers can also have reasonable medical and like costs covered if they are entitled to provisional payments for a claimed mental injury. If a worker is entitled, the reasonable costs of medical treatment and services relating to the claimed mental injury can be paid:

  • while the claim is pending, while the Agent determines whether the claim will be accepted or rejected
  • in the case of a claim rejection, up to 13 weeks after the day the worker is determined under section 75A to be entitled to provisional payments.

Reasonable costs

Reasonable cost is the amount determined by WorkSafe as reasonable in relation to a service. WorkSafe can pay for medical and like services up to the maximum amount detailed in the relevant fee schedule.

WorkSafe is only liable to pay the reasonable costs of the services if the provider has met the WorkSafe provider registration requirements.

For exampleClosedFor medical practitioners, the provider must be a registered medical practitioner within the meaning of the Health Practitioner Regulation National Law Act 2009. Medical practitioners practising in States and Territories outside Victoria must be lawfully qualified in that State or Territory for the service to be recognised. Medical practitioners outside Australia must be lawfully qualified in that place to provide that item or service and must be approved by WorkSafe.

See: A-Z of medical and like services

4.1.1 Costs WorkSafe pays

In determining what will and will not be paid for, principles of good administrative decision making must be applied. WorkSafe will only pay the reasonable cost of a service or treatment, in line with the fee schedule.

See: Decision making process | Principles of good administrative decision making

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4.1.2 Reasonable costs

Every service must be considered on its individual circumstances and merits. The Agent must consider all available information to determine if the service is necessary and appropriate in light of the specific requirements of a particular policy.

This information should be referred to in assessing liability where appropriate.

See: A-Z of medical & like services

Information to consider

Reports from:

  • treating health practitioners (especially those in a relevant discipline to the request who are primarily responsible for identifying what medical and like services the worker requires)
  • Independent Medical Examiners

Recommendations from:

  • Medical Advisors
  • Clinical Panel (a clinician from a relevant discipline)

Information in forms/documents:

  • Certificates of Capacity
  • return to work plans/arrangements
  • treatment notification forms
  • treatment review forms
  • treatment reports or any other relevant past treatment information

Any other relevant information:

  • in Novus and ACCtion eg previous decisions about approving or rejecting a particular item
    Note: prior service authorisation does not in itself set a precedent for future service.
  • additional information received eg following a request for additional information

Any additional information specific to particular policies is referred to under the relevant policy.

Liability should be assessed/determined by suitably qualified or authorised person.

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